Electronic Health Records Improve Ambulatory Care

17 Oct

According to a new study published in the Journal of General Internal Medicine, electronic health records (EHRs) significantly improve the quality of community-based ambulatory care.

Lisa M. Kern, M.D., M.P.H., of Weill Cornell Medical College in New York City, conducted a cross-sectional study with her colleagues of 2008 data for 466 general internists, pediatricians, and family medicine practitioners in ambulatory practices in New York. They found that 44 percent of the physicians had adopted electronic health records and 56 percent continued to use paper records for the total of 74,618 patients represented by the physicians in the study.
There were quality measures for nine types of care: eye exams, hemoglobin testing, cholesterol testing, renal function testing for diabetics, colorectal cancer screening, chlamydia screening, breast cancer screening, pediatric sore throat testing, and treatment for children with upper respiratory infections.
Physicians who used EHRs provided higher rates of care than physicians who used paper records, with a significant improvement in four measures: hemoglobin testing in diabetes, breast cancer screening, chlamydia screening, and colorectal cancer screening.
“We found that EHR use is associated with higher quality ambulatory care. This finding occurred in a multi-payer community with concerted efforts to support EHR implementation,” wrote the authors. “In contrast to several recent national and statewide studies, which found no effect of EHR use, this study’s finding is consistent with national efforts to promote meaningful use of EHRs.”

Meaningful Use: Stage 2 Clarifying Tips

09 Oct

Newly published information from the Centers for Medicare and Medicaid Services (CMS) that specifies the Stage 2 criteria for Meaningful Use is now available for eligible professionals, hospitals, and critical access hospitals. This information includes a tip sheet giving additional details. However, providers should keep in mind that before meeting these requirements, participants must achieve meaningful use under the Stage 1 criteria.

This tip sheet offers professionals a timeline illustrating the progression of meaningful use stages from when a Medicare provider begins participation in the program. While during the first year of participation, providers must demonstrate meaningful use for a 90-day electronic health record reporting period, the subsequent years will require a full year HER reporting period.

This full-year period is defined as an entire fiscal year for hospitals or an entire calendar year for EPs, except in 2014. Providers participating only in Medicaid HER Incentive Programs are not required to demonstrate meaningful use in consecutive years. However, their movement through the stages would follow the same structure of two years meeting the criteria of each stage, including a 90-day HER reporting period during the first year. 

As stated above, the reporting rules for 2014 differ from prior years. In 2014, all providers, regardless of their stage of meaningful use, are only required to demonstrate meaningful use for a three-month reporting period. CMS will be offering this one-time three-month reporting period in order to enable providers who must upgrade to 2014 Certified HER Technology to have time to implement their new Certified HER systems. This three-month period will be restricted for Medicare providers to the quarter of either the fiscal or calendar year. Medicaid providers who are only eligible for Medicaid EGR incentives will not be restricted to a fixed reporting period, since providers do not have the same alignment needs. 

The tip sheet explains that Stage 2 retains the core and menu structure for meaningful use objectives from Stage 1. While some Stage 1 objectives were eliminated, the majority of them are core objectives under Stage 2 and the threshold that providers must prove has simply been raised. This threshold includes demonstrating meaningful use of Certified HER Technology to a larger portion of their patient populations. 

At the core of the tip sheet are two Stage 2 criteria:

  • EPs must meet 3 menu objectives and 17 core objectives selected from a total list of 6, creating a total of 20 core objectives.
  • Hospitals that are eligible and CAHs must meet 3 menu objectives and 16 core objectives selected from a list of 6, for a total of 19 core objectives.

The tip sheet concludes with a complete list of the Stage 2 core and menu objectives for all participants, including a downloadable table. 

With the next stage of meaningful use now available, health care providers have ample resources from CMS to make sure that they meet guidelines and reap the benefits.


Overview of Health Information Exchanges

08 Oct

In keeping with the current Meaningful Use legislation, agencies across the country are developing health information exchange programs. Health Information Exchanges allow for the streamlined transmission of health-related data and patient information between health care providers and ensure this exchange is secure and up-to-date.

UC-David Health System has launched a state-wide data sharing program in California. This initiative — the California Health eQuality Program — will link hospitals, emergency departments, and physicians by 2014. In addition to a four-year, $38.8 million grant through the federal economic stimulus package, officials are seeking other funding sources to expand the program past 2014.

The initiative, as described by Kenneth Kizer, Director of the Institute for Population Health Improvement, will allow health information to “flow safely and quickly between and among health care providers…”

When will the Pacific Northwest hop on the wagon? We already have. The state of Oregon launched its statewide health information exchange, called CareAccord, in May 2012. The system will improve provider communication, reduce duplicate orders and help health care providers meet the requirements for Meaningful Use, which will allow them to qualify for Medicaid and Medicare incentive programs instituted by the Obama administration beginning in 2009.

Harris Healthcare Solutions will implement Oregon’s health information exchange and Oregon Health Authority will administer the program. Harris will employ a Direct Secure Messaging System to exchange information through any internet-enabled device, meaning that patient data will be available to practitioners on everything from laptops to mobile phones.

Other additions to the data exchange in the next phase may include:

  • Data exchange between EHR systems.
  • Record search through Master Patient Index Record Locator services.
  • Connection to federal systems, including those managed by the Department of Veterans Affairs and the Social Security Administration.

Similarly, Washington State has instituted their version of Health Exchange, One Health Port Health Information Exchange (OHP HIE). According to, “This integrated physician/hospital partnership provides patients the highest quality care through a sustainable healthcare delivery system made up of over 17 partnering clinics. This relationship effectively and efficiently meets the healthcare needs of the Greater Yakima Valley region and its people.”

Participating physicians and clinics, or trading partners, will be updated regularly and posted to the One Health Port website in the Practitioner Level Provider Directory.

In addition, to ensure the availability of data transactions, OHP HIE will include a Washington State HIE Entity Level Provider Directory. This directory will list any organization wishing to post the HIE or HIO they participate through, what transactions they are prepared to send and receive, as well as routing addresses and technical contact information for each entity.

With Meaningful Use providing benefits to health care professionals across the country, an increase in state-specific data-exchange programs like those above is likely to continue and will alter the way health care information is transmitted and processed.

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Electronic Health Records Help Docs in Emergency Care Prep

21 Sep

As hospitals increasingly adopt electronic health record systems, a new study has found that inpatient physicians who receive patients from the emergency department have begun to do “chart biopsies” of electronic records in preparation. It’s helped doctors be better prepared beforehand.

The study, published in the Journal of the American Medical Informatics Association, defines a chart biopsy as “the activity of examining a patient’s health record to orient oneself to the patient and the care that the patient has received in order to inform subsequent conversations about or care of the patient.”

The researchers spent two years at the University of Michigan Health System (UMHS), studying general internal medicine physicians and surgeons who received patients from the emergency department.

During the study, doctors had access to electronic health records for inpatient and outpatient documentation, and those used in the emergency department. When doctors and nurses in the emergency department entered data into their EHR, the inpatient doctors had immediate access to the information. Eventually, doctors began to review the emergency care charts before speaking with the physician who admitted the patient from that department.

The study defined three primary roles for the chart biopsies: provide an overview of the patient, prepare for patient handoff and subsequent care, and avoiding potential biases.

“Chart biopsies appear to impact important clinical and organizational processes,” wrote researchers. “Among these are the nature and quality of handoff interactions and the quality of care.” The study authors concluded that a “chart biopsy has the potential to enrich collaboration and to enable the hospital to act safely, efficiently, and effectively.”


Anesthesiologists Campaign Against Nurse Pain Payments

06 Sep

Last month, The American Society of Anesthesiologists (ASA) launched a nationwide campaign opposing the Centers for Medicare and Medicaid Services’ (CMS) proposal to pay nurse anesthetists for chronic pain service. The crux of the opposition is that nurse anesthetists are not equipped with the necessary formal education or training in chronic pain management.

“Even in the hands of specially trained physicians, chronic pain procedures are inherently dangerous due to the anatomy and delicate structure of the spine and nerves upon which chronic pain interventions are performed,” said ASA President Jerry A. Cohen, M.D. “Current restrictions on nurse anesthetists providing these services are appropriate and necessary in the interest of patient safety.”

In addition to the health risks, the ASA says there is also the risk of extensive and costly medical interventions. They argue the point that anesthesiologists and other doctors are better equipped to provide pain management care and minimize these risks due to their education and training, and are able to prescribe appropriate medication therapies in the process. 

Chronic pain services will often include opioids, where specialized physician training is required to minimize errors and prevent potentially lethal side effects.

“Using scarce Medicare dollars to pay nurse anesthetists to perform complicated pain service procedures unnecessarily puts patients at risk,” says Cohen. “Patients who require anesthesia or relief from pain deserve the safest and highest quality of care.”


How Patients Can Help ACOs Save Money

16 Aug

There are many ways ACOs can save money in the healthcare industry from an administrative perspective. But some of that savings will depend on patients being faithful to their medications, according to a new report.

For example, the report found that if more diabetics took their medication, a Medicare ACO with 10,000 seniors could save $1.1 million on emergency room and hospital visits every year. While thay may not sound like a lot on the national level, that’s only one example. And when you look at it on a national level, the study conservatively estimates $4.7 billion savings a year overall and $2.2 billion to Medicare. The estimates are deemed conservative because the study only included the savings from the cost of hospital stays and emergency room visits, not outpatient care.
While it’s ideal to hope that people will do this independently, there has to be an outside catalyst, if patients do not keep up with their medications already armed with the basic knowledge that it will improve or maintain their health. The researchers did n’t estimate the cost of interventions to boost drug adherence.
“As accountable care organizations and other similar entities form and take greater responsibility for the health and spending of an entire population, focusing on better adherence may be a high-yield activity,” wrote the authors in their report.
The study, published in the journal Health Affairs, examined how closely patients follow their prescriptions. The researchers did so by analyzing three years of data for 135,640 diabetes patients. They tracked changes in prescription use during the first two years (2006 and 2007) and examined hospital and emergency room visits in the third year (2008). They also took into account that some patients could be more ill than others. 
For those patients who didn’t follow their prescriptions during the first year, but who properly took medications in year two, the likelihood of a hospital or emergency room visit dropped 13 percent. The average cost per emergency room visit and hospital stay were $1,502 and $11,575 respectively.
Those patients who started on the right foot and took their medication correctly, but did not continue to do so, the likelihood of a hospital or emergency room visit jumped 15 percent. 
As for how to improve adherence to prescriptions, unfortunately the study did not go down that road.

Tighter Controls on Diabetic Supply Claims

19 Jul

Providers and suppliers will be under greater scrutiny when submitting claims for large numbers of test strips and lancets, thanks to an Office of Inspector General (OIG) June 2012 report. The OIG report estimates contractors overpaid as much as $271 million for these types of claims in 2007. In response to the report, contractors say they have made appropriate changes, or plans to do so.

Home blood-glucose test strip and lancet supplies are covered by Medicare Part B for physicians who prescribe them for their diabetic patients.
While the National Coverage Determination (NCD) does not specify utilization guidelines and documentation requirements, Local Coverage Determinations (LCDs) for the four related contractors reviewed by the report (NHIC, Corp., National Government Services, CIGNA Government Services, and Noridian Administrative Services) – state that Medicare covers up to 100 test strips and 100 lancets each month for insulin-treated diabetics, and 100 test strips and 100 lancets every three months for non-insulin-treated diabetics.
Medicare considers 50 test strips as one unit and 100 lancets as one unit. This means a standard claim for a patient’s monthly (or three-month) allotment of these supplies would be two units of A4253 blood glucose test or reagent strips for home blood glucose monitor, per 50 strips and 1 unit of A4259 Lancets, per box of 100.
To be reimbursed for a claim that exceeds these guidelines, there must be documentation that supports the reason for additional supplies and documentation in the physician’s or supplier’s records that supports the frequency of testing. The doctor must also have seen the patient and evaluated their diabetic control within six months prior to ordering the excess supplies.
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Drug Shortage Legislation Passes the House

10 Jul

Last year, The American Society of Anesthesiologists strongly urged a federal investigation into the drug shortage problem in the U.S. healthcare system. That led to The House Energy and Commerce Health Subcommittee holding a hearing in the fall they called “Examining the Increase in Drug Shortages.” Since then, there has been considerable legislative headway.

Last month, The U.S. House of Representatives overwhelmingly passed the final version of legislation that includes important provisions that address drug shortages.
S.3187, also known as the “Food and Drug Administration (FDA) Safety and Innovation Act,” was written to reauthorize the operations of the FDA’s prescription drug user fee program, which allows the FDA to collect fees from drug manufacturers to support the agency’s operations. Lawmakers, with the urging of the ASA and other advocates, also used the legislation to address drug shortages by including a section with provisions to prevent and mitigate the shortages.
Title X of the legislation requires drug manufacturers to notify the FDA when certain drugs are expected to stop being produced. This includes drugs used in the “treatment of a debilitating disease or condition” and pain drugs used in surgery (anesthesia).
The Food and Drug Administration (FDA) Safety and Innovation Act also include provisions to:
– Direct the Secretary of Health and Human Services to establish a task force to improve the response to drug shortages and create a plan to address aspects of shortages.
– Require the FDA to maintain a drug shortage list and provide it to patients, providers and the public.  
– Authorize the Government Accountability Office (GAO) to conduct a study to examine the reasons for drug shortages and give recommendations on how to prevent or alleviate the shortage. This includes data on how the regulatory framework, manufacturing challenges, or other factors contribute to drug shortages, and recommendations to address issues.
Now it’s just up to the Senate to pass the legislation and the President to sign it.

Medicare and Insurer Revenue Growth Jumps

03 Jul

According to the Standard & Poor’s Healthcare Economic Indices, healthcare professionals and hospitals saw accelerated per capita growth in revenue from Medicare and commercial insurers in the past 12 months ending in April. S&P’s healthcare composite index for that 12-month period jumped by 6.14 percent as compared to a 5.65 percent increase for the 12 months ending in March.

Breaking revenue changes down into public and private sources, Medicare fee-for-service revenue for hospitals and healthcare professionals were up by 2.6 percent in the 12 months ending last April. Commercial revenue saw a more dramatic change with an 8.46 percent increase.

“There is a clear upward trend across all annual growth rates, which began around October 2011, and we have now reached close to the top of the range of price changes established over the last few years,” said David Blitzer, index committee chairman for Standard & Poor’s Indices, in a news release. “The April increase in the composite’s annual growth rate was largely driven by a substantial jump in commercial plans.”

According to Standard & Poor’s, one of the primary purposes of their Healthcare Economic Indices is to help medical professionals and the public as a whole better understand the costs associated with healthcare. Over the last 10 years, trends of annual cost increases have varied from mid-single digits to mid-teens.

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Medicare Coverage Problems Arise with More Observation Stays

13 Jun


Hospitals all over the U.S. are labeling their patients as outpatients under observation. According to a new study, that is causing problems for people who are being covered by Medicare.
Over the last 10 years, the Center for Medicare & Medicaid Services (CMS) has put a greater emphasis on detecting Medicare fraud and curbing costs via hospital audits, which includes audits of short hospitalizations. 
According to research from a Brown University study (and maybe some good old fashioned common sense), this has lead to an increase in patient observation stays (different from a hospitalization), since hospitals can avoid an audit if they do so. The researchers found a 34 percent increase in the ratio of observation stays to inpatient hospitalizations among Medicare beneficiaries between 2007 and 2009. Also during that timespan, there was an 88 percent jump in Medicare patients held for observation stays for 72 hours or more.
Trying to reduce the number of inpatient hospitalizations may have the good intention of reducing fraudulent or medically unnecessary healthcare expenditures, patient advocates say this leaves Medicare recipients in the lurch with large and unexpected expenses.
Hospitals walk a difficult tightrope between criticism on the patient advocacy front when they appear to increase observation stays at the expense of patients and auditor with the CMS if they don’t.
The California Hospital Association states on their website that hospitals “face criticism from patients and CMS over the perceived use of observation status as a substitute for inpatient admissions, but risk penalties from CMS auditors and prosecutors when auditing admissions of short inpatient stays.”